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Head And Neck > 5 > Flashcards

5 Flashcards

1
Q

What is the junction between the pons and medullary called?

A

Ponto-medullary junction

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2
Q

What are the four nerves originating from the pons?

A
  • Trigeminal (V)
  • Abducens (VI)
  • Facial (VII)
  • Vestibulocochlear (VIII)
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3
Q

Describe the abducens nerve (CN 6)

A
  • purely motor nerve
  • innervates one muscle that abducts the eyeball: lateral rectus (extra-ocular muscle)
  • originates from lower pons (Ponto-medullary junction), the runs vertically upwards before being able to pass into cavernous sinus
  • DOES NOT run through lateral wall of cavernous sinus
  • then enters into ORBIT via SUPERIOR ORBITAL FISSURE

Clinical points

  • tested using eye movements (tests CN 3, 4, 5), such as look left look right, eye that doesn’t move is the affected one
  • patients present with diplopia (double vision)
  • microvascular complication (diabetes/hypertension) can affect the nerve (most common cause)
  • susceptible to injury in raised ICP (e.g. due to bleed, tumour, severe headache)
  • nerve can be easily stretched in raised ICP since it emerges anteriorly, at ponto-medullary junction before running under the surface of the pons upwards towards cavernous sinus; brainstem is pushed downwards causing tension to be pushed downwards, stretching the nerve
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4
Q

What is the pathway of the facial nerve (CN 7)

A
  • originates from lower pons (ponto-medullary junction)
  • then enters petrous bone via INTERNAL ACOUSTIC MEATUS
  • splits into THREE branches within the petrous bone
  • branches exit through base of skull in STYLOMASTOID FORAMEN
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5
Q

Other than innervation the muscles of facial expression, what else do the extracranial branches of the facial nerve innervate?

A
  • innervates posterior belly of digastric

- innervates stylohyoid muscle

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6
Q

Describe the functions of the facial nerve (CN 7)

A
  • Special sensory: TASTE for anterior 2/3 of tongue
  • Autonomic (parasympathetic): lacrimal glands (tears), mucosal glands in nose and roof of mouth, salivary glands (all EXCEPT parotid gland)
  • facial nerve runs through parotid gland but DOESNT supply anything to it
  • Motor: muscles of facial expression (and scalp)
  • nerve to stapedius (in middle ear) which protects ear from sound damage
  • General sensory: small area of external ear
  • ex. When you eat something and dont like it, sensed by facial nerve
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7
Q

Why is the facial nerve known as a mixed cranial nerve?

A
  • has different types of nerves (cell bodies) within the brainstem
  • has nerves carrying special sense taste
  • has autonomic fibres to glands (salivary, lacrimal, mucosal in nose and palate)
  • has nerves carrying motor to muscles of facial expression
  • has a very small area of sensory innervation within ear
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8
Q

What is the genicular ganglion?

A
  • where the cell bodies of sensory nerves are located

- for the facial nerve

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9
Q

What is the nervous intermedius?

A

-contains sensory and parasympathetic axons

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10
Q

How are motor and sensory nerves different in appearance?

A
  • motor nerves has the cell body closer to the end of an axon
  • sensory nerves have the cell body in the middle of the axon
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11
Q

What are the two roots at the cerebellopontine angle for the facial nerve?

A

Motor root and nervus intermedius

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12
Q

What are the three branches of the facial nerve that arise in the petrous bone?

A
  • Greater petrosal
  • Chorda tympani
  • Nerve to stapedius
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13
Q

Which branch of the facial nerve exits first as we leave the geniculate ganglion?

A

The greater petrosal

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14
Q

What does the greater petrosal nerve innervate?

A

-carries parasympathetic fibres to lacrimal, nasal and palatine glands

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15
Q

What does the chorda tympani nerve do?

A
  • innervates tongue and most salivary glands
  • but NOT parotid gland
  • allows parasympathetics to reach salivary glands but also carries special sensory TASTE to the anterior 2/3 of tongue
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16
Q

What does the nerve to stapedius do?

A
  • motor branch that attaches to stapes in ear

- dampens down the vibrations of sounds to stapes so it doesn’t damage it

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17
Q

Why is it important to know what area of the facial nerve is damaged?

A
  • because it could affect different functions of the face
  • if lesion is more proximal, then everything is affected
  • will experience dry eyes, droopy face, taste is messed up
  • if lesion is more distal, then only muscles of facial expression would be affected
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18
Q

What are the clinical points of the facial nerve?

A
  • clinical testing is mainly by testing muscles of facial expression (smiling, frowning)
  • also test corneal reflex
  • CN 7 lesions can present with a variety of signs and symptoms depending on where along the nerve route the pathology is
  • important to ask about other symptoms such as hyperacusis (no protection to stapedius), dry eyes, altered taste
  • middle ear pathology (in petrous bone) can sometimes involve the facial nerve
  • close relationship with vestibulocochlear nerve within posterior cranial fossa and both enter internal acoustic meatus
  • extracranial branches of facial nerve have close relationship with parotid gland
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19
Q

What is facial nerve palsy (ex. Bell’s palsy)

A

-absence of the muscles of facial expression on one side

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20
Q

What is the corneal reflex?

A
  • to see if eye closes or not
  • afferent limb of reflex is innervated by the opthalmic division of trigeminal nerve
  • efferent limb of reflex is innervated by the facial nerve
  • if facial nerve is affected then eye will be unable to close
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21
Q

Describe the passage of the vestibulocochlear nerve (CN 8)

A
  • originates from lower pons (ponto-medullary junction)
  • enters into internal acoustic meatus
  • becomes vestibulocochlear nerve
  • splits and one part goes into cochlea while the other goes into semicircular canals (vestibular system)
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22
Q

What is the function of the vestibulocochlear nerve?

A
  • is a special sensory nerve

- used for hearing and balance

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23
Q

What are the clinical points of the vestibulocochlear nerve?

A
  • crude hearing test (whisper 99 in each ear)
  • more formal hearing test i.e. pure tone audiometer if investigating hearing loss
  • enquire pt. Amount balance
  • damage involving cochlea, cochlear component of vestibulocochlear nerve, or brainstem nucleus causing hearing loss (sensorineural)
  • pathology involving semicircular canals, vestibular component of vestibulocochlear nerve, or brain nucleus causes DISTURBANCE OF BALANCE (VERTIGO)
  • acoustic neuroma
  • presbyacusis
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24
Q

What is presbyacusis?

A
  • Old-age related hearing loss

- typically corrected with hearing aids

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25
Q

What is an acoustic neuroma?

A
  • benign tumour involving vestibulocochlear nerve
  • as it enlarges, it compresses the nerve
  • tumour of the Schwann cells surrounding (vestibular component) of CN 8
  • could potentially squash facial nerve as well
  • could also rise superiorly and compress trigeminal nerve
  • physical presence causes compression of the whole nerve and more or less CNs in close proximity
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26
Q

What are the symptoms and signs of an acoustic neuroma?

A
  • unilateral hearing loss
  • tinnitus
  • vertigo
  • numbness, pain or weakness down one half of face
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27
Q

What are the four nerves from the medulla?

A
  • Glossopharyngeal (IX)
  • Vagus (X)
  • Accessory (XI)
  • Hypoglossal (XII)
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28
Q

What nerves from the medulla exit via the jugular foramen with the IJV?

A
  • Glossopharyngeal (IX)
  • Vagus (X)
  • Accessory (XI)
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29
Q

Where does the hypoglossal nerve exit to?

A

-exits through the hypoglossal canal?

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30
Q

Do all the medulla cranial nerves exit base of skull and enter into the superior part of the carotid sheath? Which nerve stays the longest?

A
  • Yes they all do

- CN 10 (vagus) stays the longest

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31
Q

What are the functions of glossopharyngeal nerve (CN 9)

A
  • Main function: sensory supply of oropharynx, posterior 1/3 tongue and middle ear
  • General sensation: (palatine) tonsils and oropharynx, middle ear and tympanic membrane (inner surface), sensory from carotid body and sinus
  • special sensory: taste and general sensation of posterior 1/3 tongue
  • Autonomic: carries parasympathetic innervation to parotid gland
  • Motor: supplies ONE muscle (stylopharyngeus) which assists in swallowing since nerve runs over surface of this muscle
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32
Q

Why do we sometimes feel ear pain when we have a sore throat?

A
  • no pathology in ear

- felt because glossopharyngeal nerve supplies sensory to both throat area and middle ear and tympanic membrane

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33
Q

What are the clinical points of glossopharyngeal nerve?

A
  • tested in conjunction with vagus nerve (CN 10), when asking pt. To swallow
  • gag reflex (sensory limb): only tested if concerns around swallowing and integrity of nerves involved in this reflex
  • stimulate the back of throat, and if pt. Feels it they will wretch or gag
  • feeling the stimulation is by glossopharyngeal but wretching in response is the vagus nerve
  • taste is not formally tested
  • isolated regions of CN 9 is very rare
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34
Q

What is the pathway of the vagus nerve (CN 10)?

A
  • originates from medulla
  • then goes into jugular foramen
  • then enters carotid sheath
  • goes through neck, into thorax and abd; gives many branches on its route
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35
Q

What is the function of the vagus nerve (CN 10)?

A
  • General sensory: sensory to lower pharynx and WHOLE larynx
  • sensory to small part of EXTERNAL ear and tympanic membrane
  • Motor: muscles of soft palate, pharynx and larynx
  • swallowing and coughing innervated by vagus nerve
  • Autonomic: parasympathetics to thoracic (eg. Heart, tracheobronchial tree) and abd viscera
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36
Q

What branch of the vagus nerve should I remember?

A
  • recurrent laryngeal nerve
  • right one turns under right subclavian
  • left one turns under arch of aorta
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37
Q

What are the clinical points of the vagus nerve?

A
  • note patient’s speech, cough and ability to swallow
  • note movement of uvula and soft palate when saying “aaah”
  • gag reflex (efferent limb)
  • isolated lesions of CN X are rare
  • injury to its branches ex. Recurrent laryngeal nerve following thyroid surgery can cause hoarseness and dysphonia (difficulty in speaking)
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38
Q

What is the function of the spinal accessory nerve (CN 11)?

A
  • Motor nerve
  • motor to SCM and trapezius
  • originates from medulla and takes little rootlets from cervical spine to join it
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39
Q

Describe the passage of the spinal accessory nerve

A
  • originates from medulla
  • emerges through jugular foramen
  • passes deep to SCM and provides its motor innervation
  • runs posterolaterally across posterior triangle (superficially)
  • enters deep to trapezius and provides its motor innervation
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40
Q

What are the clinical points of the spinal accessory nerve?

A
  • Test: shrug shoulders against resistance (trapezius)
  • Test: turn head against resistance (SCM)
  • spinal accessory nerve runs inferiorly through neck in posterior triangle (i.e. quite superficial)
  • wont affect SCM b/c already gave branches off
  • susceptible to injury in this area (SCM) (ex. In lymph node biopsies, surgery, stab wound)
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41
Q

What is the function of the hypoglossal nerve (CN 12)?

A
  • Motor nerve
  • innervates muscles of the tongue (all except one)
  • left hypoglossal does left half of tongue and right does right half
  • goes through hypoglossal canal
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42
Q

What is the passageway of the hypoglossal nerve?

A
  • Originates from medulla and enters hypoglossal canal
  • CN 12 runs medial to angle of mandible
  • crosses internal and external carotid arteries in neck
  • runs under chin to the muscles of the tongue
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43
Q

What are the clinical points of the hypoglossal nerve?

A
  • Test: inspection and movement of tongue
  • rare for pathology
  • damage to CN 12 causes weakness and atrophy of tongue muscles on IPSILATERAL Sade
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44
Q

In what week of development do the pharyngeal arches become apparent?

A

-from week 4 of developing embryo

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45
Q

What are the pharyngeal (or branchial) arches?

A
  • sequence of ridges that form in the lateral walls of the embryonic pharynx
  • towards the cranial end of the neural tube
  • complex tissue system
  • embryonic head and neck
  • involves many systems of the body, notably the brain, CVS (heart and great vessels), and special sensory organs
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46
Q

Is the face formed in the embryo at week 4?

A
  • no distinguishing external features

- BUT head and neck represent 0.5 length of embryo

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47
Q

What does each arch represent?

A
  • rep. A body segment
  • each arch has a neurovascular plan
  • develops muscles and skeletal elements
48
Q

What does each arch consist of?

A
  • large mesenchyme core (with some neural crest cells that migrate in)
  • covered by ectoderm on its external surface
  • covered by endoderm on the internal surface
49
Q

Where do the pharyngeal arches arise from and how many are there?

A
  • arise from neck region of embryo
  • 5 in total, numbered 1 to 6
  • i.e. 5th does not form in humans
  • lots of cell division occurs
50
Q

What parts constitute the building blocks of the face from the head and neck region?

A
  • frontonasal prominence which is a single unpaired midline structure
  • and pharyngeal arches
  • two maxillary prominences (swelling)
  • two manidibullar prominences (swellings)
51
Q

What is mesenchyme?

A

Primitive embryonic CT

52
Q

What does each arch have?

A

An associated artery, nerve and cartilage bar

53
Q

What is between each arch on the external surface? Describe them

A
  • pharyngeal groove or pharyngeal cleft
  • clefts usually disappear EXCEPT the first one which is between the first and second arch
  • this cleft becomes the EXTERNAL AUDITORY MEATUS of the ear
54
Q

What is between each arch on the internal surface?

A
  • pharyngeal pouches
  • glandular structures arise from these pouches
  • parathyroids, thymus and tonsils
  • first pouch is the largest and becomes the tympanic cavity
  • second pouch becomes palatine tonsil
  • third pouch becomes inferior parathyroid and thymus
  • fourth pouch becomes superior parathyroid and C cells of thyroid
55
Q

What is the pharyngeal apparatus?

A

-collection of the pharyngeal arches, grooves (clefts), and pouches

56
Q

Describe the size of the pharyngeal arches?

A
  • first one is largest and gets progressively smaller

- 4th and 6th are not visible

57
Q

What is the cartilaginous bar of the first pharyngeal arch also known as?

A
  • Meckel’s cartilage

- gives rise to mandible, malleus and incus bones

58
Q

What do the 4th and 6th arches give rise to?

A

-thyroid, arytenoids and cricoids (remain cartilaginous)

59
Q

What cranial nerves associate with the pharyngeal arches?

A
  • CN V, VII, IX and X (5, 7, 9, 10)
  • have mixed sensory and motor functions
  • supply the derivatives of the pharyngeal arches
  • CN XI and CN XII have relationship with pharyngeal arch system
60
Q

Why does the recurrent laryngeal nerve of the ages become looped under arch of aorta and subclavian artery?

A
  • due to rearrangement of developing structures
  • each pharyngeal arch becomes associated with an aortic arch blood vessel
  • appears very organized at first but then embryo develop and structures start to derive from the pharyngeal arches
61
Q

What are the muscular derivatives of the first pharyngeal arch?

A
  • muscles of mastication (CN 5)
  • mylohyoid
  • anterior belly of digastric*
  • tensor tympani
  • tensor Veli palatine
62
Q

What are the muscle derivatives of the second pharyngeal arch?

A
  • muscles of facial expression (CN 7)
  • stapedius
  • stylohyoid
  • posterior belly of digastric
63
Q

What are the muscle derivatives of the third arch?

A

-stylopharyngeus (muscle of pharynx)

64
Q

What are the muscle derivatives of the 4th arch?

A
  • criciothyroid
  • levator palatine
  • constrictors of pharynx
65
Q

What are the muscle derivatives of the sixth arch?

A

-intrinsic muscles of the larynx?

66
Q

What are the cartilages of the first arch?

A
  • Meckel’s cartilage

- Maxillae and zygomatic bones

67
Q

What are the skeletal/cartilages of the second arch?

A
  • Reichert’s cartilage
  • superior part of hyoid
  • stapes
  • styloid process
  • stylohyoid ligament
68
Q

What are the skeletal/cartilages of the third arch?

A

-inferior part of body of hyoid

69
Q

What are the cartilages of the third and fourth arch?

A

-epiglottis

70
Q

What are the cartilages of the fourth and 6th arch?

A

-cartilages of the larynx

71
Q

How do the cartilages of the arches start off?

A
  • each arch starts off as a simple rod-shaped cartilaginous structure
  • work to keep gills rigid and allow for gas exchange
  • rod-like bars get remodelled to make appropriate structure
72
Q

What are the arteries of the first and second pharyngeal arch?

A

-dont have any, they disappear

73
Q

What is the artery for the third arch?

A

Internal carotid

74
Q

What is the artery for the fourth arch?

A

-aortic arch (left) and subclavian artery (right)

75
Q

What are the arteries for the sixth arch?

A

-pulmonary arteries?

76
Q

What is the nerve for the first arch?

A

Trigeminal (V)

77
Q

What is the nerve for the second arch?

A

Facial nerve (VII)

78
Q

What is the nerve for the third arch?

A

Glossopharyngeal (IX)

79
Q

What is the nerve for the fourth and sixth arches?

A

Vagus (X)

80
Q

What happens is the pharyngeal clefts do not close up properly?

A
  • branchial cyst or branchial fistulae could occur
  • SCM can help identify as it is a key landmark
  • marks where normal fusion occurs
  • if there is a lump anterior to SCM then it could possibly be a branchial cyst
81
Q

What drives development of the face?

A
  • expansion of the cranial neural tube
  • appearance of a complex tissue system associated with:
  • cranial gut tube
  • outflow of the developing heart
  • development of sense organs and the need to separate the resp. Tract from the GI tract
82
Q

What is the first evidence of face development?

A

-appearance of a depression in the ectoderm on the ventral aspect of the head

83
Q

What is a stomadaeum?

A
  • site of future mouth

- buccopharyngeal membrane

84
Q

What parts of the face will the frontonasal prominence form?

A

-forehead, bridge of nose, upper eyelids and centre of upper lip (philtrum)

85
Q

What parts of the face will the laterally paired maxillary prominences form?

A
  • middle third of face
  • upper jaw
  • most of lip and sides of nose
  • cheeks
86
Q

What parts of the face will the paired mandibular prominences form?

A
  • lower third of face

- lower jaw and lower lip

87
Q

What is the facial primordia?

A
  • consists of first pharyngeal arch (maxillary and mandibular prominences)
  • FNP which surrounds ventro-;arterial part of forebrain
  • primordia of eyes begin development on lateral side of head
88
Q

What is the first evidence of nose formation?

A

-appearance of two ectodermal thickenings (nasal placodes) on either side of midline on ventrolateral aspect of FNP

89
Q

What is a placode?

A
  • name given to an area of ectoderm that starts to thicken and differentiate itself from its surrounding tissue to give rise to sensory structure
  • also an optic placode from which future ear develops
90
Q

After the nasal placodes are formed, what happens next?

A
  • placodes invaginate and form deep pits known as NASAL PITS
  • nasal pits eventually become nostril
  • horseshoe-shaped ridge forms around entrance to each nostril
  • “arms” of the horseshoe are the medial and lateral nasal prominences
  • deepening nasal pits are separated by the oronasal membrane
  • oronasal membrane disappears so that the oral and nasal cavities become one continuous space
91
Q

What is the oronasal membrane?

A

-thing sheet cells that separate the deepening nasal pits which lie dorsal to the stomodaeum

92
Q

After the separation of the nasal pits, what happens next?

A
  • development of the palate
  • involves the maxillary prominences and the medial nasal prominences
  • medial nasal prominences merge in the midline, separating the nostrils from the mouth and creating the intermaxillary segment
  • maxillary prominences fuse with medial nasal prominences
  • nasal prominences form the philtrum of upper lip and a small midline component of the palate (primary palate or premaxillary portion)
  • palatal shelf grows from each maxillary prominence vertically downwards, on either side of tongue, towards the midline
  • they fuse with each other and with primary palate
  • fusion creates secondary palate which separates nasal cavity from oral cavity
  • mandible grows large enough for tongue to “drop”
93
Q

What is cleft lip and palate?

Vl

A

Lateral cleft lip
-failure of fusion of medial nasal prominence and maxillary prominence
Cleft lip and cleft palate
-above combined with failure of palatal shelves to meet in midline

  • can be due to genetics and environmental factors, mostly congenital abnormalities
  • can be diagnosed antenatally with ultrasound or after delivery
  • if left uncorreted, will cause problems with feeding and perch
  • most common facial birth defect
  • doctor will take neonatal exam before discharge, including feeling the hard palate with a gloved finger to check for the presence of cleft
  • clefts can be corrected with surgery
  • cleft lips at around 3 months (for cosmetic reasons)
  • palate repairs are later at 9-12 months
94
Q

How do the ears develop?

A
  • external auditory meatus develops from first pharyngeal cleft
  • middle ear cavity and ossicles develop from first pharyngeal pouch and cartilages of first and second arches respectively
  • auricles develop from proliferation within first and second pharyngeal arches surrounding the meatus
95
Q

Explain the positioning of the ears

A
  • external ears develop initially in the neck
  • as mandible grows, the ears ascend to the side of head to lie in line with the eyes
  • all common chromosomal abnormalities have associated external ear anomalies
96
Q

What is fetal alcohol syndrome?

A
  • no known safe alcohol consumption during pregnancy
  • facial Skeleton derived from neural crest cells populating the pharyngeal arches
  • neural crest migration as well as development of the brain are known to be extremely sensitive to alcohol
  • incidence of FAS and ARND= 1/100 births
  • alcohol extremely toxic to developing neurons and neural crest cells
97
Q

What parts of the face does the medial nasal prominence form?

A

Philtrum, primary palate, mid upper jaw

98
Q

What part of the face does the lateral nasal prominence form?

A

Cheeks, lateral upper lip, secondary palate, lateral upper jaw

99
Q

What consequence will occur if olfactory nerve is damaged?

A

Loss of olfaction

100
Q

What will happen if optic nerve or oculomotor nerve is damaged?

A

Fixed dilated pupil

101
Q

What will happen if optic branch of facial nerve is damaged?

A

Inability to close eye

102
Q

What will happen if opthalmic division of trigeminal nerve or facial nerve is damaged?

A

Loss of blink reflex

103
Q

What will happen if there interruption to sympathetic innervation to eyelid?

A

Partial drooping of eyelid (partial ptosis)

104
Q

What will happen if oculomotor nerve is damaged

A

Complete drooping of eyelid (complete ptosis)

105
Q

What will happen if maxillary division of trigeminal nerve was damaged? (Trigeminal neuralgia)

A

Intermittent sharp shooting pain over cheek

106
Q

What will happen if opthalmic division of trigeminal nerve is damaged? (Opthalmic shingles)

A

Ulcerated lesions over eyelids and cornea

107
Q

What will happen if facial or glossopharyngeal nerve is damaged?

A

Altered taste sensation

108
Q

What nerves are damaged in numbness of tongue?

A

Lingual nerve (branch of mandibular division of trigeminal)

109
Q

What nerve was damaged in difficulty swallowing?

A

Vagus and a bit of glossopharyngeal, minor role)

110
Q

What nerve is damaged in hoarseness of voice?

A

Vagus nerve

111
Q

What nerve is damaged in weakness of tongue?

A

Hypoglossal nerve

112
Q

Into what three “spaces” do the 3 branches of the trigeminal nerve arise?

A
  • Opthalmic: into superior orbital fissure
  • Maxillary: through foramen rotundum into pterygopalatine fossa
  • Mandibular: through foramen ovale into infratemporal fossa
113
Q

Which cranial nerves pass into the orbit?

A

-oculomotor, optic, and opthalmic branch of trigeminal

114
Q

What is the cavernous sinus? What are its borders?

A
  • potential space involving blood vessel
  • floor: endosteal layer of dura mater that overlies the base of the greater wing of sphenoid bone
  • roof: meningeal layer of dura mater that attaches to the anterior and middle cricoid processes of sphenoid bone
  • anterior: superior orbital fissure
  • posterior: petrous part of temporal bone
  • medial: body of sphenoid bone
  • lateral: meningeal layer of dura mater running from roof to the floor of middle cranial fossa
115
Q

What goes through the cavernous sinus?

A

O TOM CAT

Oculomotor, Trigeminal, Opthalmic, Maxillary, Carotid, Abducens, Trochlear

Head And Neck (11 decks)

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